{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T05:11:30Z","timestamp":1788757890426,"version":"build-2803163510"},"reference-count":45,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T00:00:00Z","timestamp":1788739200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Nutr."],"abstract":"<jats:p>\n                    Malnutrition, sarcopenia and frailty are common in advanced liver disease and predict poorer survival, encouraging simple blood-based indices when formal assessment is impractical. The most widely used, the Prognostic Nutritional Index (PNI), combines serum albumin and the peripheral lymphocyte count; yet both have been reported to be strongly influenced by systemic inflammation as well as by nutrition, and the index is seldom benchmarked against a disease-specific reference or against albumin alone. We evaluated whether the PNI provides clinically useful prognostic information for short-term mortality in critically ill patients with liver disease, using three independent cohorts: a North American intensive-care primary cohort (\n                    <jats:italic>n<\/jats:italic>\n                    = 3,653), a multicentre external-validation cohort (\n                    <jats:italic>n<\/jats:italic>\n                    = 922) and a single-center Chinese cohort in which hepatitis B was the leading cause of liver disease (\n                    <jats:italic>n<\/jats:italic>\n                    = 453). In each cohort we quantified discrimination of 28-day or in-hospital mortality, compared the PNI with serum albumin alone and with the Model for End-Stage Liver Disease (MELD), and tested whether it improved discrimination or reclassification beyond MELD. The PNI discriminated death only marginally better than chance (area under the curve 0.52\u20130.56) and no better than albumin alone, so its lymphocyte component added no independent signal; the weak per-standard-deviation association seen in the primary cohort was not significant in either validation cohort. MELD discriminated substantially better everywhere (0.67\u20130.70). The conventional PNI threshold classified 89\u201397% of patients as abnormal and was uninformative. Across three case-mixes the PNI behaved as a weak, non-specific prognostic discriminator, adding nothing to MELD, MELD-Na or MELD 3.0; in an exploratory paired subgroup, re-measurement on days 3\u20137 did not improve discrimination. This is consistent with its components tracking systemic inflammation and chronic physiologic reserve\u2014an axis largely orthogonal to the acute organ failure that drives short-term mortality. Separating the index into its components and testing incremental value provides the comparative evidence this literature has lacked. The PNI was assessed as a discriminator of short-term mortality, not as a measure of nutritional status: nutritional risk is better identified with instruments validated for that purpose, and mortality risk with MELD.\n                  <\/jats:p>","DOI":"10.3389\/fnut.2026.1930417","type":"journal-article","created":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T04:23:23Z","timestamp":1788755003000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["The prognostic nutritional index vs. MELD for short-term mortality in critically ill liver disease: a retrospective multi-cohort study"],"prefix":"10.3389","volume":"13","author":[{"given":"Lujun","family":"Shao","sequence":"first","affiliation":[{"name":"Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University","place":["Taizhou, China"]},{"name":"Graduate School of Medicine, Hirosaki University","place":["Hirosaki, Japan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yue","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University","place":["Taizhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cheng","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University","place":["Taizhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Li","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University","place":["Taizhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huiyu","family":"Tai","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Unit, The Affiliated Taizhou People's Hospital of Nanjing Medical University","place":["Taizhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,7]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"172","DOI":"10.1016\/j.jhep.2018.06.024","article-title":"European Association for the Study of the Liver. EASL clinical practice guidelines on nutrition in chronic liver disease","volume":"70","author":"Merli","year":"2019","journal-title":"J Hepatol"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1611","DOI":"10.1002\/hep.32049","article-title":"Malnutrition, frailty, and sarcopenia in patients with cirrhosis: 2021 practice guidance by the American Association for the Study of Liver Diseases","volume":"74","author":"Lai","year":"2021","journal-title":"Hepatology"},{"key":"B3","doi-asserted-by":"publisher","first-page":"485","DOI":"10.1016\/j.clnu.2018.12.022","article-title":"ESPEN guideline on clinical nutrition in liver disease","volume":"38","author":"Plauth","year":"2019","journal-title":"Clin Nutr"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.clnu.2018.08.002","article-title":"GLIM criteria for the diagnosis of malnutrition \u2013 a consensus report from the global clinical nutrition community","volume":"38","author":"Cederholm","year":"2019","journal-title":"Clin Nutr"},{"key":"B5","doi-asserted-by":"publisher","first-page":"564","DOI":"10.1002\/hep.29219","article-title":"Development of a novel frailty index to predict mortality in patients with end-stage liver disease","volume":"66","author":"Lai","year":"2017","journal-title":"Hepatology"},{"key":"B6","first-page":"1001","article-title":"Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients","volume":"85","author":"Onodera","year":"1984","journal-title":"Nihon Geka Gakkai Zasshi"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1706534","DOI":"10.3389\/fnut.2025.1706534","article-title":"Prognostic value of Prognostic Nutritional Index in cancer: an umbrella review of systematic review and meta-analysis","volume":"12","author":"Yang","year":"2026","journal-title":"Front Nutr"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1439","DOI":"10.1038\/bjc.2012.92","article-title":"A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: the prognostic nutritional index (PNI)","volume":"106","author":"Pinato","year":"2012","journal-title":"Br J Cancer"},{"key":"B9","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1002\/jpen.1451","article-title":"Hypoalbuminemia: pathogenesis and clinical significance","volume":"43","author":"Soeters","year":"2019","journal-title":"JPEN J Parenter Enteral Nutr"},{"key":"B10","doi-asserted-by":"publisher","first-page":"1385","DOI":"10.1016\/j.jhep.2014.08.010","article-title":"Cirrhosis-associated immune dysfunction: distinctive features and clinical relevance","volume":"61","author":"Albillos","year":"2014","journal-title":"J Hepatol"},{"key":"B11","doi-asserted-by":"publisher","first-page":"464","DOI":"10.1053\/jhep.2001.22172","article-title":"A model to predict survival in patients with end-stage liver disease","volume":"33","author":"Kamath","year":"2001","journal-title":"Hepatology"},{"key":"B12","doi-asserted-by":"publisher","first-page":"1887","DOI":"10.1053\/j.gastro.2021.08.050","article-title":"MELD 3","volume":"161","author":"Kim","year":"2021","journal-title":"Gastroenterology"},{"key":"B13","doi-asserted-by":"publisher","first-page":"2408","DOI":"10.1161\/CIRCULATIONAHA.109.192278","article-title":"Criteria for evaluation of novel markers of cardiovascular risk: a scientific statement from the American Heart Association","volume":"119","author":"Hlatky","year":"2009","journal-title":"Circulation"},{"key":"B14","doi-asserted-by":"publisher","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"370","author":"von Elm","year":"2007","journal-title":"Lancet"},{"key":"B15","doi-asserted-by":"publisher","first-page":"e078378","DOI":"10.1136\/bmj-2023-078378","article-title":"TRIPOD+AI statement: updated guidance for reporting clinical prediction models that use regression or machine learning methods","volume":"385","author":"Collins","year":"2024","journal-title":"BMJ"},{"key":"B16","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1038\/s41597-022-01899-x","article-title":"MIMIC-IV, a freely accessible electronic health record dataset","volume":"10","author":"Johnson","year":"2023","journal-title":"Sci Data"},{"key":"B17","doi-asserted-by":"publisher","first-page":"180178","DOI":"10.1038\/sdata.2018.178","article-title":"The eICU Collaborative Research Database, a freely available multi-center database for critical care research","volume":"5","author":"Pollard","year":"2018","journal-title":"Sci Data"},{"key":"B18","doi-asserted-by":"publisher","first-page":"e215","DOI":"10.1161\/01.CIR.101.23.e215","article-title":"PhysioBank, PhysioToolkit, and PhysioNet: components of a new research resource for complex physiologic signals","volume":"101","author":"Goldberger","year":"2000","journal-title":"Circulation"},{"key":"B19","doi-asserted-by":"publisher","first-page":"818","DOI":"10.1097\/00003246-198510000-00009","article-title":"APACHE II: a severity of disease classification system","volume":"13","author":"Knaus","year":"1985","journal-title":"Crit Care Med"},{"key":"B20","doi-asserted-by":"publisher","first-page":"1018","DOI":"10.1056\/NEJMoa0801209","article-title":"Hyponatremia and mortality among patients on the liver-transplant waiting list","volume":"359","author":"Kim","year":"2008","journal-title":"N Engl J Med"},{"key":"B21","doi-asserted-by":"publisher","first-page":"2957","DOI":"10.1001\/jama.1993.03510240069035","article-title":"A new Simplified Acute Physiology Score (SAPS II) based on a European\/North American multicenter study","volume":"270","author":"Le Gall","year":"1993","journal-title":"JAMA"},{"key":"B22","doi-asserted-by":"publisher","first-page":"1297","DOI":"10.1097\/01.CCM.0000215112.84523.F0","article-title":"Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients","volume":"34","author":"Zimmerman","year":"2006","journal-title":"Crit Care Med"},{"key":"B23","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: development and validation","volume":"40","author":"Charlson","year":"1987","journal-title":"J Chronic Dis"},{"key":"B24","doi-asserted-by":"publisher","first-page":"801","DOI":"10.1001\/jama.2016.0287","article-title":"The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)","volume":"315","author":"Singer","year":"2016","journal-title":"JAMA"},{"key":"B25","first-page":"1","article-title":"KDIGO clinical practice guideline for acute kidney injury","volume":"2","author":"Kidney","year":"2012","journal-title":"Kidney Int Suppl"},{"key":"B26","doi-asserted-by":"publisher","first-page":"1711","DOI":"10.1097\/CCM.0b013e31828a24fe","article-title":"A new severity of illness scale using a subset of Acute Physiology and Chronic Health Evaluation data elements shows comparable predictive accuracy","volume":"41","author":"Johnson","year":"2013","journal-title":"Crit Care Med"},{"key":"B27","doi-asserted-by":"publisher","first-page":"837","DOI":"10.2307\/2531595","article-title":"Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach","volume":"44","author":"DeLong","year":"1988","journal-title":"Biometrics"},{"key":"B28","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1002\/sim.2929","article-title":"Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond","volume":"27","author":"Pencina","year":"2008","journal-title":"Stat Med"},{"key":"B29","doi-asserted-by":"publisher","first-page":"1389","DOI":"10.1109\/LSP.2014.2337313","article-title":"Fast implementation of DeLong's algorithm for comparing the areas under correlated receiver operating characteristic curves","volume":"21","author":"Sun","year":"2014","journal-title":"IEEE Signal Process Lett"},{"key":"B30","doi-asserted-by":"publisher","first-page":"268","DOI":"10.7326\/M16-2607","article-title":"Sensitivity analysis in observational research: introducing the E-value","volume":"167","author":"VanderWeele","year":"2017","journal-title":"Ann Intern Med"},{"key":"B31","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v045.i03","article-title":"mice: multivariate imputation by chained equations in R","volume":"45","author":"van Buuren","year":"2011","journal-title":"J Stat Softw"},{"key":"B32","doi-asserted-by":"publisher","first-page":"1092059","DOI":"10.3389\/fnut.2022.1092059","article-title":"Prognostic nutritional index: a potential biomarker for predicting the prognosis of decompensated liver cirrhosis","volume":"9","author":"Xie","year":"2022","journal-title":"Front Nutr"},{"key":"B33","doi-asserted-by":"publisher","first-page":"3885","DOI":"10.3390\/jcm15103885","article-title":"Comparative prognostic accuracy of objective nutritional indices in critically ill patients with sepsis: a systematic review and meta-analysis","volume":"15","author":"Yang","year":"2026","journal-title":"J Clin Med"},{"key":"B34","doi-asserted-by":"publisher","first-page":"385","DOI":"10.1097\/SHK.0000000000000993","article-title":"Neutrophil-to-lymphocyte ratio predicts death in acute-on-chronic liver failure patients admitted to the intensive care unit: a retrospective cohort study","volume":"49","author":"Moreau","year":"2018","journal-title":"Shock"},{"key":"B35","doi-asserted-by":"publisher","first-page":"319","DOI":"10.1097\/01.SLA.0000055547.93484.87","article-title":"Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials","volume":"237","author":"Vincent","year":"2003","journal-title":"Ann Surg"},{"key":"B36","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1097\/SHK.0000000000000234","article-title":"Persistent lymphopenia after diagnosis of sepsis predicts mortality","volume":"42","author":"Drewry","year":"2014","journal-title":"Shock"},{"key":"B37","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1097\/MEG.0000000000000993","article-title":"Red blood cell distribution width independently predicts 1-month mortality in acute decompensation of cirrhotic patients admitted to emergency department","volume":"30","author":"Turcato","year":"2018","journal-title":"Eur J Gastroenterol Hepatol"},{"key":"B38","doi-asserted-by":"publisher","first-page":"e0167000","DOI":"10.1371\/journal.pone.0167000","article-title":"Prognostic value of red blood cell distribution width in non-cardiovascular critically or acutely patients: a systematic review","volume":"11","author":"Luo","year":"2016","journal-title":"PLoS ONE"},{"key":"B39","doi-asserted-by":"publisher","first-page":"1735","DOI":"10.1007\/s10620-015-4015-z","article-title":"The Royal Free Hospital-Nutritional Prioritizing Tool is an independent predictor of deterioration of liver function and survival in cirrhosis","volume":"61","author":"Borhofen","year":"2016","journal-title":"Dig Dis Sci"},{"key":"B40","doi-asserted-by":"publisher","first-page":"166","DOI":"10.1016\/j.cgh.2011.08.028","article-title":"Muscle wasting is associated with mortality in patients with cirrhosis","volume":"10","author":"Montano-Loza","year":"2012","journal-title":"Clin Gastroenterol Hepatol"},{"key":"B41","doi-asserted-by":"publisher","first-page":"e102","DOI":"10.1038\/ctg.2015.31","article-title":"Inclusion of sarcopenia within MELD (MELD-Sarcopenia) and the prediction of mortality in patients with cirrhosis","volume":"6","author":"Montano-Loza","year":"2015","journal-title":"Clin Transl Gastroenterol"},{"key":"B42","doi-asserted-by":"publisher","first-page":"1151","DOI":"10.1016\/j.jhep.2014.02.026","article-title":"Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography","volume":"60","author":"Durand","year":"2014","journal-title":"J Hepatol"},{"key":"B43","doi-asserted-by":"publisher","first-page":"1759","DOI":"10.1038\/ajg.2016.303","article-title":"A rapid bedside screen to predict unplanned hospitalization and death in outpatients with cirrhosis: a prospective evaluation of the Clinical Frailty Scale","volume":"111","author":"Tandon","year":"2016","journal-title":"Am J Gastroenterol"},{"key":"B44","doi-asserted-by":"publisher","first-page":"565","DOI":"10.1177\/0272989X06295361","article-title":"Decision curve analysis: a novel method for evaluating prediction models","volume":"26","author":"Vickers","year":"2006","journal-title":"Med Decis Making"},{"key":"B45","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1097\/EDE.0b013e3181c30fb2","article-title":"Assessing the performance of prediction models: a framework for traditional and novel measures","volume":"21","author":"Steyerberg","year":"2010","journal-title":"Epidemiology"}],"container-title":["Frontiers in Nutrition"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnut.2026.1930417\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T04:23:24Z","timestamp":1788755004000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnut.2026.1930417\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,7]]},"references-count":45,"alternative-id":["10.3389\/fnut.2026.1930417"],"URL":"https:\/\/doi.org\/10.3389\/fnut.2026.1930417","relation":{},"ISSN":["2296-861X"],"issn-type":[{"value":"2296-861X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,7]]},"article-number":"1930417"}}